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Papers by Richard Douce

Open Forum Infectious Diseases, Nov 1, 2018

Background. Vancomycin-resistant Enterococcus (VRE) is transmitted from person-to-person, most co... more Background. Vancomycin-resistant Enterococcus (VRE) is transmitted from person-to-person, most commonly by healthcare workers (HCW) whose hands or attire have become contaminated while interacting with an infected or colonized patient. Our group recently found that VRE colonized patients transmitted this pathogen to HCW gowns or gloves 15% of the time. This study aims to describe patient-level factors associated with higher risk of transmission of VRE to HCW gowns or gloves and thus likely to subsequent patients. Methods. We analyzed a prospective cohort that included 43 VRE-colonized patients and 215 HCW-patient interactions in medical or surgical intensive care units at the University of Maryland Medical Center. HCWs' gowns and gloves were cultured for VRE after performing patient care and before doffing. Univariate and multivariable logistic regression models, using generalized estimating equations to account for patient clustering, were used to estimate the odds ratios associated with specific patient-level factors (i.e., age, race, Elixhauser comorbidity score components obtained by ICD-10 codes, diarrhea, and devices). Multivariable models with and without stool VRE burden were created. Results. In the initial multivariable model, having a nasogastric tube, diarrhea, complicated diabetes, rheumatoid arthritis/collagen vascular diseases, neurological disorders or psychoses doubled (OR greater than 2) the patient's risk of VRE transmission. After adjusting for VRE stool burden (OR 2.1 (95% CI 1.5-3.0)), having a nasogastric tube (OR 3.6 (95% CI 1.3-9.8)), diarrhea (OR 3.3 (95% CI 1.4-8.1)), or rheumatoid arthritis/collagen vascular diseases (OR 4.8 (95% CI 1.6-14.7)) remained significant in the model. Conclusion. Patient-level factors associated with higher risk of VRE transmission to HCW gowns or gloves were identified even after adjusting for VRE stool burden, highlighting the importance of patient characteristics in VRE transmission. These patient-level factors may facilitate transmission by either increasing VRE stool shedding to the environment or the need for direct HCW-patient contact. These factors could be used to target more aggressive infection control interventions for these patients. Disclosures. All authors: No reported disclosures.

Spartan medical research journal, Feb 2, 2017

Lyme disease is the most common tick-borne infection found in the eastern United States. In recen... more Lyme disease is the most common tick-borne infection found in the eastern United States. In recent years, it has become an emergent Michigan public health concern. Lyme carditis is a recognized rare complication which is classically characterized by rapidly fluctuating degrees of heart block. In severe cases, or if inappropriately treated, Lyme carditis can also result in profound bradycardia, perimyocarditis, and sudden cardiac death. This report describes the first documented case of third degree heart block associated with Lyme carditis to occur in Michigan. This is a retrospective case report of a patient evaluated and treated for Lyme carditis in Southwest Michigan in July, 2016. All information was obtained from either the patient or his electronic medical record. Despite initial misdiagnosis and inappropriate management, this patient ultimately received more appropriate medical therapy within 24 hours of first presentation. After eight days of high dose intravenous Ceftriaxone and supportive care, and more than two weeks of oral Doxycycline, the patient's symptoms resolved and the disease was treated to resolution. Neither permanent nor temporary pacing was needed during/after the course of treatment. When correctly identified, Lyme disease and Lyme carditis can be easily treated. Although this patient's history was without reported tick bite or exposure to a known host for Lyme disease, the authors believe that the patient's history and physical exam was definitive enough to warrant the start of IV therapy with telemetry monitoring upon first presentation. The fact that the condition was not first diagnosed by providers indicates a potential gap in medical knowledge and awareness that should be addressed in clinical practice. The authors consider this case a harbinger of the emerging disease of Lyme carditis. Physical exam and EKG findings should guide clinicians' therapeutic approaches. Although treatment with appropriate antibiotics is typically curative, therapeutic delays can lead to deadly results.

Influenza and Other Respiratory Viruses, Mar 1, 2009

Background Recent influenza antiviral resistance studies reveal an alarming increase in both adam... more Background Recent influenza antiviral resistance studies reveal an alarming increase in both adamantanes and neuraminidase inhibitors (NAIs) resistant viral strains worldwide, particularly in Asia, Europe and the United States. Objectives In this study, we have evaluated influenza virus resistance in Central and South America. Methods Influenza viruses, isolated from symptomatic patients throughout Central and South America in 2005-2008 were analyzed for inhibitor resistance. The M2 and NA genes of influenza viruses were sequenced and resistance was inferred by comparison with published sequences and known resistant mutations. Results Our results indicate that: (i) resistance to adamantanes was seen in the majority (95AE5%) of the influenza A ⁄ H3N2 isolates but only in one isolate of the influenza A ⁄ H1N1 viruses; (ii) resistance to NAIs began to be detected in A ⁄ H1N1 isolates from Central America in 2008; and (iii) none of the influenza B viruses analyzed were resistant to NAIs. Conclusions These findings suggest a limited effectiveness of influenza inhibitors due to the detection of resistance among A ⁄ H1 and A ⁄ H3 viruses.

American Journal of Tropical Medicine and Hygiene, Sep 5, 2012

We present a 44-year-old man from a rural community in northern Ecuador who worked on a cattle fa... more We present a 44-year-old man from a rural community in northern Ecuador who worked on a cattle farm where he was involved with primary veterinary care, including assistance during births (or calving) and placenta retention and artificial insemination, with minimal precautions. In September of 2009, quite abruptly, he developed asthenia and hypersomnia without any apparent cause or symptoms like fever, chills, or night sweats. On November 14, 2009, he suffered from pain and edema in the right testicle that coincided with pain in the abdomen. Clinical, serological, and bacteriological investigations confirmed the first case of unilateral orchitis in man in Ecuador caused by Brucella abortus biovar 1. Because brucellosis is a neglected disease, special attention should be given to it in the training of medical and veterinary students.

Journal of Clinical Microbiology, Jun 1, 1986

Parasite-specific humoral and cellular immune responses were evaluated in nine immunosuppressed p... more Parasite-specific humoral and cellular immune responses were evaluated in nine immunosuppressed patients with Strongyloides stercoralis infection. Four patients had the disseminated form of the disease, and five had serious manifestations without evidence of hyperinfection. All patients had high levels of immunoglobulin G (IgG) antibodies directed against S. stercoralis larval antigens as detected by the enzyme-linked immunosorbent assay. Seven patients had both elevated total serum IgE and parasite-specific IgE antibodies detected by a modified radioimmunoassay. The hyperinfected patients differed significantly from the nonhyperinfected group hi total and specific IgE levels and peripheral eosinophilia but not in specific IgG levels. None of the patients tested exhibited significant in vitro lymphoproliferative responses to parasite antigens. Our results indicated that the possibility of a protective role of IgE and eosinophils in strongyloidiasis deserves further investigation. In addition, we suggest that the enzyme-linked immunosorbent assay for specific IgG antibodies may have an important place in the diagnosis of strongyloidiasis in immunocompetent as well as in immunocompromised patients.

Revista Prevenção de Infecção e Saúde, Mar 20, 2023

Introduction: Hepatitis B surveillance is crucial. We proposed to describe the seroprevalence of ... more Introduction: Hepatitis B surveillance is crucial. We proposed to describe the seroprevalence of Hepatitis B infection and the associated factors among Ecuadorian Amazonia communities. Outline: A serologic cross-sectional study was carried out in subjects over two years old. We classified seropositivity according to the Centers of Diseases Control criteria and recorded sex, age, temporary migration, sometime Hepatitis B in their life, and previous vaccination. Results: Out of 215 participants, 50.0%, 8.8%, 1.9%, and 1.4% were susceptible, immune due to natural infection, chronic infection, and early acute HBV infection, respectively. Of the 8 people who reported having ever been diagnosed with Hepatitis B, none showed chronic or acute infection and one was positive for immunity due to the vaccine. HBsAg was found in 3.3% (95% IC 0.9-7.0) and was higher among those who migrate 7.7% (p-value 0.04). 16.3% (95% CI 11.6-21.4) was immune due to HBV vaccination. Among the 58 participants who declared having received the vaccine, 20.7% presented post-vaccine immunity. Implications: Participants who should have benefited from the vaccination campaign (susceptible) are those with the lowest immune response due to vaccination. To assessing the burden of viral hepatitis in people living in marginalized areas and guide preventive measures is mandatory.

American Journal of Case Reports, Jun 29, 2021

Patient: Male, 65-year-old Final Diagnosis: Mycobacterium avium intracellulare epidural abscess S... more Patient: Male, 65-year-old Final Diagnosis: Mycobacterium avium intracellulare epidural abscess Symptoms: Back pain • flank pain Medication: — Clinical Procedure: Debridement • evacuation of epidural abscess • laminectomy Specialty: Infectious Diseases • Neurosurgery Objective: Unusual clinical course Background:Mycobacterium avium intracellulare complex (MAI) is a member of the non-tuberculous mycobacteria family, which can cause both pulmonary and non-pulmonary disease. In patients with advanced HIV, it is known to cause disseminated disease. We present a case of a 65-year-old man who has sex with men (MSM) with AIDS, found to have spondylodiscitis and an epidural abscess, who had recently completed treatment for disseminated MAI.Case Report:The patient was a 65-year-old with AIDS secondary to HIV and a prior history of disseminated MAI, who presented with severe back pain. Upon presentation to the hospital, an MRI was performed, which was suggestive of spondylodiscitis and an epidural abscess. He was taken to surgery for a minimally invasive T12-L1 laminectomy and evacuation of the epidural abscess. Both traditional cultures and acid-fast bacillus (AFB) cultures were negative. Due to worsening pain, he was taken back to surgery for a repeat debridement and biopsy. Repeat cultures were positive for MAI. He was started on rifabutin, ethambutol, azithromycin, and moxifloxacin. Moxifloxacin was subsequently discontinued. He has had problems tolerating the treatment regimen, but is planned to complete an 18–24-month course.Conclusions:For patients with AIDS who have a diagnosis of spondylodiscitis and an epidural abscess, an opportunistic infection such as MAI should be considered. A repeat biopsy should be considered if suspicion is still high, even despite initially negative cultures. Treatment regimens should be prolonged, despite difficulty with medication compliance.

Journal of Community Hospital Internal Medicine Perspectives, Nov 2, 2018

Objective: The objective of this study was to review the impact of an automatic email notificatio... more Objective: The objective of this study was to review the impact of an automatic email notification to infectious disease consultants. Design: Cases were identified from a community hospital system microbiology database by at least one positive blood culture. Records were reviewed both before (2013 and 2014) and after (2015 and 2016) the implementation of the automated email system (intervention). Prior to this policy, consultation with the infectious disease (ID) specialist was at the discretion of the primary team. Results: There were no significant differences in 30-day mortality between the two groups (18 vs 20%, p = 0.10). However, a trend of shorter hospital stays (12.2 vs 9.5 days, p = 0.03) and reduced 30 day readmissions (40% vs 19%, p = 0.03) was observed and antibiotics prescribed for complicated cases was more appropriate (57% vs 85%, p = 0.004). Conclusions: In this study population, the implementation of an automatic email generator to ID specialists was associated with a shorter hospital length of stay, less 30-day readmissions and more appropriate length of antibiotics prescribed in complicated cases of SAB. The authors recommend future studies replicating the methodology employed here with larger sample sizes before consideration of employing a similar automatic email ID consult generation at other health systems.

Antimicrobial Agents and Chemotherapy, Mar 1, 1985

Forty-three hospitalized patients were treated with a new antibiotic combination containing ticar... more Forty-three hospitalized patients were treated with a new antibiotic combination containing ticarcillin plus the beta-lactamase inhibitor, clavulanic acid, in a fixed combination for intravenous use. A variety of infections were treated, including pneumonia, bacteremia, urinary tract infection, and osteomyelitis. Of 50 episodes of infection in 43 patients, 44clinical cures were obtained, with 5 patients improving and 1 patient failing to respond to treatment. In vitro susceptibility testing of 101 clinical isolates was notable for the rarity of resistance to the combination antibiotic. Of specific interest, all 14 isolates of Staphylococcus aureus were susceptible to ticarcillin plus clavulanic acid, whereas only 2 of the 14 isolates were susceptible to ticarcillin alone. Adverse reactions to the study drug were minimal; eosinophilia, unaccompanied by other allergic phenomena, and oral candidiasis were most frequent. Overall, the combination of ticarcillin with the beta-lactamase inhibitor, clavulanic acid, appears to be a safe and effective drug for the treatment of infections caused by susceptible organisms.

Open Forum Infectious Diseases

Background Eastern equine encephalitis virus is a mosquito-borne alphavirus responsible for unpre... more Background Eastern equine encephalitis virus is a mosquito-borne alphavirus responsible for unpredictable outbreaks of severe neurologic disease in animals and humans. While most human infections are asymptomatic or clinically nonspecific, a minority of patients develops encephalitic disease, a devastating illness with a mortality rate of ≥30%. No treatments are known to be effective. Eastern equine encephalitis virus infection is rare in the United States, with an annual average nationwide incidence of 7 cases between 2009 and 2018. However, in 2019, 38 cases were confirmed nationwide, including 10 in Michigan. Methods Data from 8 cases identified by a regional network of physicians in southwest Michigan were abstracted from clinical records. Clinical imaging and histopathology were aggregated and reviewed. Results Patients were predominantly older adults (median age, 64 years), and all were male. Results of initial arboviral cerebrospinal fluid serology were frequently negative, a...

Revista Prevenção de Infecção e Saúde

Abstract. An outbreak of delta hepatitis occurred during 1998 among the Waorani of the Amazon bas... more Abstract. An outbreak of delta hepatitis occurred during 1998 among the Waorani of the Amazon basin of Ecuador. Among 58 people identified with jaundice, 79 % lived in four of 22 Waorani communities. Serum hepatitis B surface antigen (HBsAg) was found in the sera of 54 % of the jaundiced persons, and 14 % of asymptomatic persons. Ninetyfive percent of 105 asymptomatic Waorani had hepatitis B core (HBc) IgG antibody, versus 98 % of 51 with jaundice. These data confirm that hepatitis B virus (HBV) infection is highly endemic among the Waorani. Sixteen of 23 (70%) HBsAg carriers identified at the onset of the epidemic had serologic markers for hepatitis D virus (HDV) infection. All 16 were jaundiced, where as only two of seven (29%) with negative HDV serology were jaundiced (P �.0006). The delta cases clustered in families, 69 % were children and most involved superinfection of people chronically infected with HBV. The data suggest that HDV spread rapidly by a horizontal mode of transm...

Abstract. Wound botulism results from colonization of a contaminated wound by Clostridium botulin... more Abstract. Wound botulism results from colonization of a contaminated wound by Clostridium botulinum and the anaerobic in situ production of a potent neurotoxin. Between 1943, when wound botulism was first recognized, and 1990, 47 laboratory-confirmed cases, mostly trauma-associated, were reported in the United States. Since 1990, wound botu-lism associated with injection drug use emerged as the leading cause of wound botulism in the United States; 210 of 217 cases reported to the Centers for Disease Control and Prevention between 1990 and 2002 were associated with drug injection. Despite the worldwide distribution of Clostridium botulinum spores, wound botulism has been reported only twice outside the United States, Europe, and Australia. However, wound botulism may go undiagnosed and untreated in many countries. We report two cases, both with type A toxin, from the Ecuadorian rain forest. Prompt clinical recognition, supportive care, and administration of trivalent equine botulinum...

The American Journal of Case Reports, 2021

Spartan Medical Research Journal, 2017

CONTEXT Empiric antibiotics are often required in hospitalized patients with serious infections w... more CONTEXT Empiric antibiotics are often required in hospitalized patients with serious infections who may be septic and at risk for drug resistant organisms. The purpose of this study was to evaluate the observed incidence of acute kidney injury (AKI) in a sample of adult patients receiving either piperacillin-tazobactam and vancomycin or meropenemvancomycin for at least 72 hours. METHODS Single-center, retrospective matched cohort at a 200-bed Regional Community Medical Center. Adult patients were included in the sample if they were without preexisting renal dysfunction and admitted over an 18-month time period to receive either the combination of piperacillin-tazobactam and vancomycin or meropenem-vancomycin. Sample patients were evaluated for AKI. This condition was defined by the authors as an increase in serum creatinine of 0.5mg/ml or an increase of 50% above baseline during the duration of antibiotic treatment. RESULTS A total of 266 patients receiving either combination of ant...

Background: Tropical countries are thought to play an important role in the global behavior of re... more Background: Tropical countries are thought to play an important role in the global behavior of respiratory infections such as influenza. The tropical country of Ecuador has almost no documentation of the causes of acute respiratory infections. The objectives of this study were to identify the viral agents associated with influenza like illness (ILI) in Ecuador, describe what strains of influenza were circulating in the region along with their epidemiologic characteristics, and perform molecular characterization of those strains. Methodology/Findings: This is a prospective surveillance study of the causes of ILI based on viral culture of oropharyngeal specimens and case report forms obtained in hospitals from two cities of Ecuador over 4 years. Out of 1,702 cases of ILI, nine viral agents were detected in 597 patients. During the time of the study, seven genetic variants of influenza circulated in Ecuador, causing six periods of increased activity. There appeared to be more heterogen...

Emerging Infectious Diseases

Journal of Community Hospital Internal Medicine Perspectives